title: Effect of cervical spine immobilization technique on pediatric advanced airway management: a high-fidelity infant simulation model.
abstract: OBJECTIVE
  Current guidelines recommend cervical spine immobilization during orotracheal intubation when traumatic injury is suspected in infants. We evaluated the effect of cervical spine immobilization techniques on orotracheal intubation performance with a high-fidelity infant simulator.
  
  
  METHODS
  A randomized control study with repeated measurement. Nonanesthesia pediatric practitioners certified for intubation performed 6 intubations with 3 different cervical spine immobilization techniques (no physical protection, manual in-line immobilization, and cervical collar: C-collar). Time to accomplish key actions, cervical extension angle, and observed intubation associated events such as mainstem intubation, esophageal intubation with or without immediate recognition were recorded.
  
  
  RESULTS
  Twenty-six practitioners performed 156 successful orotracheal intubation. Time to intubation from end of mask assist ventilation was 29.0 +/- 12.2 seconds in no physical protection, 33.0 +/- 17.4 seconds in C-collar, and 33.0 +/- 17.1 seconds in manual in-line immobilization (P = 0.39). Maximal cervical extension angle in no physical protection (2.39 +/- 2.56 degrees ) and C-collar (2.65 +/- 1.79 degrees ) were significantly greater compared with 0.85 +/- 1.05 degrees in manual in-line immobilization (P < 0.0001). The number of intubation attempts and intubation associated events were not different among 3 techniques. Laryngeal visualization measured by Cormack-LehaneScale was more difficult in C-collar compared with other 2 techniques (P< 0.001).
  
  
  CONCLUSIONS
  In this high-fidelity infant simulator model, cervical spine immobilization technique affected cervical extension angle and laryngeal visualization. Tracheal intubation associated events occurred in 33% of intubation attempts but were not different by technique. Time to achieve tracheal intubation, number of intubation attempts needed to succeed, and intubation-associated events were not affected by immobilization techniques. These results support Advanced Trauma Life Support recommendations to perform manual in-line immobilization in infants.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA. nishisaki@email.chop.edu
authors.forename: Akira
authors.initials: A
authors.lastname: Nishisaki
authors.forename: Louis
authors.initials: L
authors.lastname: Scrattish
authors.forename: John
authors.initials: J
authors.lastname: Boulet
authors.forename: Mandip
authors.initials: M
authors.lastname: Kalsi
authors.forename: Matthew
authors.initials: M
authors.lastname: Maltese
authors.forename: Thomas
authors.initials: T
authors.lastname: Castner
authors.forename: Aaron
authors.initials: A
authors.lastname: Donoghue
authors.forename: Roberta
authors.initials: R
authors.lastname: Hales
authors.forename: Lisa
authors.initials: L
authors.lastname: Tyler
authors.forename: Peter
authors.initials: P
authors.lastname: Brust
authors.forename: Mark
authors.initials: M
authors.lastname: Helfaer
authors.forename: Vinay
authors.initials: V
authors.lastname: Nadkarni
mesh_terms: D000402:Airway Obstruction / Q000628:therapy*; D002574:Cervical Vertebrae; D002983:Clinical Competence; D004638:Emergency Treatment; D006776:Hospitals, Pediatric; D006801:Humans; D007103:Immobilization / Q000295:instrumentation / Q000379:methods*; D007223:Infant; D007442:Intubation, Intratracheal / Q000379:methods*; D020704:Laryngoscopes; D008954:Models, Biological; D011336:Probability; D012680:Sensitivity and Specificity; D013119:Spinal Cord Injuries; D013131:Spine